ADR - Senores Pharmaceuticals

If you or your patient/ relative have faced any adverse drug experience, please fill the following form for us to serve you better.

Who are you?

I am a Healthcare ProfessionalI am a Relative of the PatientI am the Patient and ReporterI am a Senores Pharmaceuticals Employee or Vendor

What's your complaint?

Adverse Drug Experience(s)Product Quality Complaint(s)

Your details

Name

Mobile Number with Country Code

Email

City

Postal Code

Country

Details of the patient

Patient’s Name (We will keep this confidential)

Age

Gender

Height

Weight(Kg)

Ethnicity

Race

I, the patient/ reporter, provide my consent to Senores Pharmaceuticals to contact me via

EmailPhoneBoth

Details of the Product being reported

Product Name

Indication for Use

Lot Number

Expiry Date

Dose

Frequency

Start Date

Stop Date

Ongoing

Describe the adverse drug experience(s) or your product quality complaint(s)

Start Date

Stop Date

Did any of the following occur as a result of the adverse drug experience(s)?

DeathHospitalization – Initial/ ProlongedImmediate threat to lifePermanent or significant disability/ incapacityCongenital anomaly

Please provide the medical history of the patient

Description	Disease/ Disorder	Disease/ Disorder	Disease/ Disorder
Start date
Stop date
Ongoing

Is the patient taking any other medications?

YesNo

If yes, provide the details of the other medicines

	Drug 1	Drug 2	Drug 3	Drug 4	Drug 5	Drug 6
Product name
Indication for use
Dose
Frequency
Start date
Stop date
Ongoing

If you or your patient/ relative have faced any adverse drug experience, please fill the following form for us to serve you better.

Who are you?

What's your complaint?

Your details

Details of the patient

I, the patient/ reporter, provide my consent to Senores Pharmaceuticals to contact me via

Details of the Product being reported

Describe the adverse drug experience(s) or your product quality complaint(s)

What has been the outcome of the adverse drug experience(s)?

Did any of the following occur as a result of the adverse drug experience(s)?

Please provide the medical history of the patient

Description

Disease/ Disorder

Disease/ Disorder

Disease/ Disorder

Is the patient taking any other medications?

If yes, provide the details of the other medicines

Drug 1

Drug 2

Drug 3

Drug 4

Drug 5

Drug 6

Would you like to share any other information related to the case?